As the costs of healthcare continue to rise, healthcare policy makers and physicians are pushing for more evidence-based medical decision-making. Medical technology and interventions have to be proven that they not only improve quality of life but also are cost-effective. Consequently, the overall goal of this proposed program is to provide Dr. Nguyen-Huynh with didactic teaching in study design, database management, multivariate and cost-effectiveness analyses, along with mentoring and clinical duties, to enable her development as an independent investigator in cerebrovascular medicine. Her project on acute outcome and management of TIA with carotid disease will provide her the chance to apply her new skills and knowledge. Atherosclerotic disease in the internal carotid artery (ICA) is a common cause of stroke and TIA. Clinical trials have demonstrated a clear benefit of carotid endarterectomy (CEA) over medical management in patients with TIA or minor stroke and severe ICA stenosis. In addition, studies have found the short-term stroke risk after TIA to be substantial. These results would suggest that an urgent carotid ultrasound should be done in all appropriate TIA patients and potentially an endarterectomy if severe disease is found. Current guidelines for the management of TIA patients recommend a carotid artery examination, but do not specify the timeframe for which this diagnostic evaluation should be carried out. We propose a series of studies to examine the need for an urgent diagnostic work-up and management of TIA patients with severe carotid disease. These studies will include: 1) a stroke-free survival analysis of a large cohort of TIA patients with severe ICA stenosis compared to those without severe disease; 2) a retrospective cohort study of TIA patients who underwent CEA to determine the surgical risks of "early" (equal to or less than 30 days after incident TIA) vs. "delayed" (more than 30 days) surgery using multivariate analysis; 3) a cost-effectiveness analysis of "urgent" carotid ultrasound after a TIA. The results of these studies will provide physicians with evidence-based recommendations, and will foster Dr. Nguyen-Huynh's career as an independent clinical investigator in cerebrovascular diseases.